将军事爆炸暴露与退伍军人健康管理局诊断相关联：千年队列研究中的慢性健康结局

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中文摘要

背景与目标： 探讨美国退伍军人在接受退伍军人健康管理局（VHA）医疗保健期间，高水平爆炸（HLB）暴露及军事服役期间低水平爆炸（LLB）暴露的职业风险与随后慢性医学诊断之间的关联。
方法： 千年队列研究是一项基于人群的队列研究，纳入自2001年开始入组的美国军人及退伍军人，并每3-5年通过调查进行随访。分析纳入2001年至2013年间入组、完成2011-2013年调查、已从军队退役、具有完整爆炸暴露及协变量数据，并在随访期间至少接受VHA医疗保健2个日历年的参与者。HLB通过自我报告的爆炸或爆震所致损伤进行评估。LLB风险使用军事职业专业代码进行分类。对2013年至2021年VHA记录的 incident 诊断进行分析，使用改良Poisson回归估计调整患病率比（APRs）和95% CIs。
结果： 在N = 36,641名退伍军人中，HLB暴露与多种VHA记录的 incident 诊断可能性增加相关，包括乙型肝炎（APR [1.46]；95% CI [1.13-1.89]）、丙型肝炎（1.89；[1.30-2.75]）、糖尿病（1.28；[1.07-1.52]）、高胆固醇血症（1.31；[1.18-1.46]）、高脂血症（1.12，[1.06-1.18]）、肥胖（1.07，[1.01-1.15]）、癫痫发作（1.79；[1.47-2.18]）、心绞痛（1.43；[1.18-1.73]）、高血压（1.08；[1.02-1.15]）、其他心脏疾病（1.15；[1.05-1.28]）、卒中（1.35；[1.05-1.74]）、慢性支气管炎（1.28；[1.07-1.52]）、肺气肿（1.26；[1.05-1.52]）、鼻窦炎（1.13，[1.04-1.23]）、神经病变（1.38；[1.24-1.54]）和膀胱感染（1.54；[1.14-2.08]）。LLB暴露的职业风险与丙型肝炎（0.67；[0.45-0.97]）、糖尿病（0.84；[0.72-0.99]）、高脂血症（0.94；[0.90-0.99]）、鼻窦炎（0.91；[0.85-0.99]）和克罗恩病（0.62；[0.41-0.94]）的可能性降低相关。乙型肝炎观察到显著的乘法交互作用（1.92；[1.13-3.25]）。加法交互作用估计通常为次加性，提示高职业风险的LLB减弱而非放大了HLB与大多数结局之间的关联。
讨论： 在接受VHA医疗保健的退伍军人中，军事服役期间的HLB暴露与退役多年后多种临床状况的较高患病率相关。这些发现提示爆炸暴露代表一种长期职业健康风险，对神经系统疾病负担和全身健康具有影响。

英文摘要

BACKGROUND AND OBJECTIVES: To examine associations between high-level blast (HLB) exposure and occupational risk for low-level blast (LLB) exposure during military service and subsequent chronic medical diagnoses among US Veterans receiving Veterans Health Administration (VHA) care.
METHODS: The Millennium Cohort Study is a population-based cohort study of US service members and Veterans enrolled beginning in 2001 and followed with surveys every 3-5 years. Analyses included participants enrolled between 2001 and 2013 who completed the 2011-2013 survey, had separated from military service, had complete blast and covariate data, and used VHA care for at least 2 calendar years during follow-up. HLB was assessed by self-report of injury resulting from blast or explosion. LLB risk was classified using military occupational specialty codes. Incident VHA-documented diagnoses from 2013 to 2021 were analyzed using modified Poisson regression to estimate adjusted prevalence ratios (APRs) and 95% CIs.
RESULTS: Among N = 36,641 Veterans, HLB exposure was associated with increased likelihood of several VHA-documented incident diagnoses, including hepatitis B (APR [1.46]; 95% CI [1.13-1.89]), hepatitis C (1.89; [1.30-2.75]), diabetes (1.28; [1.07-1.52]), hypercholesterolemia (1.31; [1.18-1.46]), hyperlipidemia (1.12, [1.06-1.18]), obesity (1.07, [1.01-1.15]), seizures (1.79; [1.47-2.18]), angina (1.43; [1.18-1.73]), hypertension(1.08; [1.02-1.15]), other heart condition (1.15; [1.05-1.28]), stroke (1.35; [1.05-1.74]), chronic bronchitis (1.28; [1.07-1.52]), emphysema (1.26; [1.05-1.52]), sinusitis (1.13, [1.04-1.23]), neuropathy (1.38; [1.24-1.54]), and bladder infection (1.54; [1.14-2.08]). Occupational risk for LLB exposure was associated with lower likelihood of hepatitis C (0.67; [0.45-0.97]), diabetes (0.84; [0.72-0.99]), hyperlipidemia (0.94; [0.90-0.99]), sinusitis (0.91; [0.85-0.99]), and Crohn disease (0.62; [0.41-0.94]). A significant multiplicative interaction was observed for hepatitis B (1.92; [1.13-3.25]). Additive interaction estimates were generally subadditive, suggesting that high occupational risk for LLB attenuated rather than amplified the associations between HLB and most outcomes.
DISCUSSION: Among Veterans receiving VHA care, HLB exposure during military service was associated with a higher prevalence of several clinical conditions years after separation from service. These findings suggest that blast exposure represents a long-term occupational health risk with implications for neurologic disease burden and systemic health.